17: Lesbian, Gay, Bisexual, & Transgender Patients

Lesbian, gay, bisexual, and transgender (LGBT) people have become more openly accepted into the framework of society. Likewise, the medical literature has expanded its discussion of the health needs of LGBT people, though often addressing the issues from a strictly sexual behavior perspective (e.g., “men who have sex with men”). Specific knowledge and skills are essential for the health care provider to be able to ascertain the sexual orientation and gender identity of patients; communicate acceptance and understanding of LGBT health issues; screen for conditions amenable to behavioral interventions; and provide information and resources specific to the needs of LGBT patients. Providers can use these skills to provide access to competent medical care for LGBT patients.

Lesbians and gay men make up anywhere from 1% to 10% of the general population—depending on the source quoted and the sampling method used in the study. In most studies, self-identified bisexuals are a small fraction of the lesbian or gay population. Whatever the exact percentage, however, in absolute terms, LGBT persons constitute a significant group of patients with unique medical, psychological, and social needs. Sexual orientation and gender identity are generally invisible. Consequently, many health care providers caring for LGBT patients do not recognize or acknowledge their unique needs.

Sexual Orientation, Sexual Behavior, & Identity

Sexual orientation refers to sexual attraction to another person, including fantasies and the desire for sex, affection, and love. Sexual orientation is distinct from and not necessarily predictive of sexual behavior or activities. Being gay, lesbian, or bisexual assumes awareness of this sexual attraction to people of the same gender or both genders, respectively, and development of an identity based on this awareness. Emotions, psychological responses, societal expectations, individual choices, and cultural influences are all factors that form this identity. Most lesbians and gay men prefer the terms lesbian and gay, because such terms incorporate emotions, behavior, and a cultural system, as well as sexual orientation. Compared to the term homosexual, often interpreted as more clinical and sometimes pejorative, gay and lesbian are more accepted terms.

Sexual orientation, sexual behavior, and identity are interrelated but function independently. Most self-identified lesbians and gay men are sexually active with a partner of their own gender. However, despite this identity, some lesbians and gay men are celibate or have sexual partners of the opposite gender. In fact, most lesbians have had at least one sexual experience with a man, but would not self-identify as bisexual. On the other hand, some men and women who identify as bisexual enter into and codify long-term relationships with a partner of the opposite gender while maintaining sexual relationships with partners of the same gender. Because of the variable relationship between orientation, behavior, and identity, physicians must remain sensitive, open-minded, and nonjudgmental (see section “Provider–Patient Interactions”).

Race and ethnicity have a strong influence on sexual identity and behavior. “Down low,” a colloquial term coined in African American hip-hop culture, refers to nondisclosure of same-sex sexual behavior among men who identify as heterosexual. Sexual behavior in conflict with sexual identity is not unique to African American men. Men and women from racial and ethnic minority communities are less likely to identify as gay, lesbian, or bisexual because of the complex interactions of homophobia (see section “Homophobia and Transphobia”), religious institutions and influences, and cultural norms. As an example, the concept of machismo or masculinity is highly valued in Latino culture. A gay male Latino identity runs counter to this norm.

Gender Identity, Gender Expression, & Gender Roles

Gender identity refers to the deep-seated beliefs, emotions, and thoughts that create the self-perception of being male or female. A person is considered transgender when gender identity conflicts with biological or genetic sex. Many in the transgender community use the terms cis-gender (referring to a gender unchanged from birth) and trans-gender, (referring to a gender that changes from a gender assigned at birth), although these terms are relatively new. Gender expression is the behavioral manifestation of gender identity. Toddlers and school-age children often engage in sex-discordant gender expression normally. In transgender individuals, this conflict between sex and gender is pervasive and long lasting. The current edition of the Diagnostic and Statistical Manual defines transgender as “Gender Dysphoria”, replacing the previous “gender identity disorder”, an imperfect but important move away from characterizing transgender individuals as diseased.

The gender expression and roles that transgender people exhibit vary widely, influenced by personal preference and access to health care resources. Some transgender men and women may only desire an outward physical appearance (e.g., hair style, cosmetics, clothing) consistent with their identity. Others may seek cosmetic and/or full sex reassignment surgery. Many transgender individuals interact with the health care system actively in transition from one gender to another.

The spectrum of gender identity is distinct from sexual orientation and identity. A transgender person can have either same-gender sexual attraction, opposite-gender sexual attraction, or both. Regardless of the gender of sexual partners, transgender individuals do not necessarily identify as gay, lesbian, or bisexual.

Many LGBT patients are not comfortable identifying as one specific “letter,” that is L, G, B, or T, and prefer broader terms like “Queer” or “Gender Queer.” “Queer,” which was formerly used as a derogatory term for LGBT people, has now been reclaimed by portions of the LGBT community as an inclusive term. Queer is often used by younger members of the LGBT community to refer to a sexual orientation outside of the usual binary. Others will still consider this an offensive term, so it is important for providers to consider an individual’s feelings when using such terms and not assume one term fits each patient.

Homophobia & Transphobia

Homophobia is defined as an irrational fear of or prejudice against gay men, lesbians, and bisexuals. Transphobia is a more recent term reflecting a similar fear or prejudice against transgender individuals. In daily life, LGBT individuals experience homophobia and transphobia as interpersonal, workplace, societal, or political bias. In other words, homophobia and transphobia reflect prejudice or hatred based solely on perceptions of sexual orientation and gender identity. LGBT people often find it difficult to act in accordance with their identity for fear of bias, discrimination, or violence.

The stigma that accompanies attitudes of homophobia and transphobia contributes to chronic stress (sometimes called “minority stress”) and negative health outcomes for LGBT persons. Societal discrimination both creates a disparity in social support and resources and limits access to appropriate health care resources. Internalized homophobia (i.e., self-hatred) and self-concealment can create adverse mental health outcomes. Conversely, disclosure of LGBT identity often leads to better psychological adjustment. However, if self-disclosure by an LGBT individual is not supported, it can lead to its own stressor and risk behaviors (see section “Coming Out”).

Provider Bias

LGBT patients frequently report detrimental experiences with health care providers. In a survey of its members, the Gay and Lesbian Medical Association reported that more than 50% of respondents were aware of substandard care delivery because of a patient’s sexual orientation. In an earlier survey of nursing students, 8–12% of those responding “despised” gays and lesbians. Several studies document negative reactions after patients self-disclose their identity to a provider and such reactions have been shown to lead to worsened health outcomes for these patients.

Each negative experience with a health care provider decreases the likelihood that LGBT patients will continue to seek health care. Providers must work to overcome judgmental attitudes and biases toward LGBT patients. The Code of Ethics of the American Medical Association states that professional obligation limits a physician’s prerogative to choose whether to enter into a relationship with a patient, in that “physicians cannot refuse to care for patients based on race, gender, [or] sexual orientation ….” Health care providers must recognize that they will likely encounter patients of all orientations and identities in the daily practice of medicine (see section “Provider–Patient Interactions”).

The provider–patient relationship is the key to providing competent and respectful care to LGBT patients. Without a good provider–patient relationship, patients may avoid medical care. Providers who are uncomfortable working with LGBT patients, or who fail to recognize the sexual orientation of a patient, will not provide quality care. Patients who do not obtain competent primary care services, including screening and health risk and psychosocial counseling are likely to have a lower health status than their heterosexual counterparts. Providers can develop a good relationship with LGBT patients by showing an understanding of their health needs and communicating a nonjudgmental attitude.

Overcoming Barriers to Communication

Many LGBT persons are reluctant to share their sexual orientation with health care providers for fear of negative judgments and homophobic responses. Some fail to share this information even when asked directly. Unpleasant experiences with health care providers have made LGBT people more likely to avoid health care and routine screening. Even sympathetic health care providers are often uncomfortable with the interaction. They may lack experience with LGBT health issues or feel unsure as to what language to use to elicit information respectfully from these patients. When both patient and provider are uncomfortable, important information is not shared.

The Sexual History

Gathering information about a patient’s sexual orientation or sexual practices is often a challenge for health care providers. Asking about orientation only while taking a sexual history and not at other times can limit the opportunity to learn important details about the patient. The initial focus should be on sexual behavior, not identity, as many people with same-sex partners do not identify as gay or lesbian, and sexual orientation is a complex, multifaceted concept. Therefore, the provider should avoid questions that presume behavior or identity. Examples include: “What form of birth control do you use?” “Are you married, single, widowed, or divorced?” “When was the last time you had intercourse?” Because the options given do not necessarily pertain to them, the patient must either provide false information or awkwardly stop and explain. Needing to give such explanations can make obtaining an already challenging sexual history even more difficult for both parties. To avoid this awkwardness, or to avoid negatively impacting the provider-patient relationship, patients may play along with the assumption of heterosexuality, which may negatively impact their health care.

The Social History

This may be a more comfortable part of the interview in which to raise issues of sexual orientation. By asking questions that do not have heterosexual assumptions, the provider can increase the opportunities for, and comfort level in, discussing these issues. Providers learn about the patient’s family structure, any stressors the patient might have, and personal and community resources on which patients would be likely to draw.

Sensitive Communication

Because LGBT people come in all shapes, sizes, ages, and colors, providers need to use questions that avoid bias with all men and women, not just those they suspect of being LGBT. Sensitive questions make no assumptions about sexual orientation and are easily phrased: “Are you single, partnered, married, widowed, or divorced?” “Who is in your immediate family?” “Over your lifetime, have your sexual partners been men, women, or both?”

In the initial visit with the patient, it is important to discuss explicitly the documentation of sexual orientation in the chart. Many LGBT persons keep their sexual orientation hidden for legal, employment, or child custody reasons. A direct question, such as, “How do you feel about my documenting your sexual orientation on the chart?” may be asked. When an LGBT patient does not want sexual orientation documented, providers can use a coded entry. The code serves to remind providers of the patient’s sexual orientation for medical purposes but will prevent inadvertent breaches of confidentiality.

As a relationship develops between the patient and the provider, it is appropriate to inquire more deeply about a patient’s gender identity or sexual practices. For example, a provider may use one of the following questions: “If you become ill, is there someone important whom I should involve in your care?” or “What percentage of the time do you practice safer sex?” Transgender individuals very early in a transition to another gender may have an appearance that is discordant from the intended gender. Others may have not yet changed the assigned sex or name on legal documents or the medical record. It is perfectly acceptable to inquire about the preferred use of personal pronouns: “What name do you prefer? Would you prefer I address you as he or she?”

Enhancing the Relationship

Providers who show a nonjudgmental attitude are much more likely to develop trusting relationships with gay and lesbian patients. Providers can improve the relationship in several simple ways: offering to include a partner in the discussions, ensuring that an LGBT patient’s partner is treated as a spouse in the office and the hospital, including partners in discussions of next-of-kin policies and advance directives, and using office and hospital forms with words that do not assume a heterosexual family structure.

Lesbian, Gay, Bisexual, and Transgender Providers

Lesbian, gay, bisexual, and transgender patients often prefer working with LGBT health care providers because of the presumed absence of homophobia in the relationship. LGBT providers, however, train in the same settings as their heterosexual counterparts and, thus, may have learned communication skills without recognizing heterosexual bias. Gradually, more information is emerging about lesbian and gay health issues (though not as much about bisexual or transgender issues), and new language habits for bias-free communication are being disseminated.

Lesbian and gay providers may find themselves in a situation in which the question of whether to disclose their own sexual orientation to their patients arises. The question the providers should ask themselves is whether disclosure of sexual orientation is in the best interest of the patient. In many cases, such disclosure may be beneficial. When a patient clearly needs to understand that there will be no overt homophobia in the interaction before agreeing to remain in care, it may be reassuring to know that the provider is LGBT. As patient–provider relationships develop, patients often want more personal information about the provider. LGBT providers must weigh for themselves the therapeutic benefit to the patient, the patient’s need for information, and their own level of comfort in self-disclosure. Although many LGBT physicians have reported ostracism, harassment, and professional discrimination from colleagues, teachers, administrators, and health plans, others report being open about their sexual orientation without experiencing any negative consequences.

The process of discovering one’s sexual orientation and/or gender identity and revealing it to others is known as coming out and can occur at any age. Stage theories for coming out have been well described and have been summarized as a four-step process:

1. Awareness of homosexual and/or transgender feelings

2. Testing and exploration

3. Identity acceptance

4. Identity integration and self-disclosure

Recent research suggests that there may be different sequences of coming out for younger and older individuals, with individuals who come out in adolescence often identifying and disclosing themselves as homosexual prior to any consensual sexual experiences. The process of coming out involves a shift in core identity that can be associated with significant emotional distress, especially if family and peers respond negatively. Prevailing social attitudes also influence the experience. Most often, individuals come out to other people in person, but some may choose to come out initially through virtual arenas, a process with its own potentially complicating factors, including issues of privacy or unintended disclosure to other individuals. Societal and internalized homophobia often causes lesbians, gay men, and bisexual individuals to perform a fatiguing “cost–benefit” analysis for each situation in which they consider coming out. This process can be even more taxing for transgender persons as each situation may involve issues of both orientation and gender identity. Data show that women who have children before coming out are slower in reaching developmental milestones in this process than either women without children or women who have children after coming out. If the costs of self-disclosure are repeatedly high, an individual may ultimately become socially isolated or revert to denying their LGBT identity. On the other hand, disclosing at work and working for more gay-supportive organizations correlates with higher job satisfaction and lower anxiety at work.

In 2011, the Institute of Medicine released a report that examined LGBT health and health disparities through the life stages. Adolescence is characterized by the transition from being a dependent child to an independent young adult. It is complicated by the physical and emotional changes that occur during puberty. Early and middle adulthood, here considered together, is roughly the period from the early 20s to the 60s. It begins with the ending of puberty and continues through the completion of formal education and the establishment of financial independence. For some it includes the selection of a partner and building a family, whether this means the introduction of children or a close community of friends. Later adulthood is then a period of continued growth but also, for many, the onset of disease. During this period, LGBT people may become dependent on health care providers and feel uncomfortable disclosing their LGBT identities. Although many of the stages that follow can occur at any stage of life, they are listed during the stage in which they most commonly occur.

Adolescents

Coming Out

LGBT adolescents are particularly vulnerable to the emotional distress of coming out, and this distress can make adolescent development even more difficult (see Chapter 13). Adolescents who self-identify as lesbian or gay prior to consensual sexual experiences may have a more rapid progression through the coming out stages, have fewer or no heterosexual encounters, and may engage in less risky sexual experiences. Cultural factors, such as race and ethnicity, do not seem to hamper the formation of identity but may delay the integration of identity with behavior.

Parental acceptance of the adolescent during the coming out process may be the primary determinant of healthy self-esteem. Research by Ryan et al. (see Suggested Readings) demonstrated that teens that have been rejected by their families are more than eight times more likely than their cohorts to have attempted suicide. They were also more likely to suffer from depression, anxiety, and low self-esteem, to perform worse in school, and more likely to engage in risk-taking behaviors such as high-risk sexual behavior or substance abuse. Teens that come out in school may be more likely to be teased or bullied and even threatened with a weapon. In many instances, these teens feel unsupported by teachers or parents. Indeed, teens may feel fearful of or bullied by their parents or siblings and feel unsafe at home. This can lead to increased feelings of isolation, hopelessness, and suicidality.

Primary care providers need to screen for signs that adolescents are questioning their sexual orientation. These signs may include depression, diminished school performance, alcohol and substance abuse, acting out, and suicidal ideation. Providers noting these signs need to consider distress regarding sexual orientation in the differential diagnosis, along with depression and substance abuse. Providers also need to be willing to discuss sexual orientation with their adolescent patients, as their attempts to discuss same-sex attractions and homosexual orientations may be the patient’s first disclosure of these feelings. If providers meet such reaching out with reticence, dismay, or contempt, then adolescents may be less likely to share their feelings with others and either revert to denial or engage in more covert, risky behaviors.

Social Media

In the past, LGBT individuals have sought out others in the community by finding bars, social clubs, or community spaces frequented by other LGBT people. This is difficult in more rural areas or where the population of LGBT people is sparse or where many people are not out. The Internet, and more specifically social media, allows LGBT individuals to network with people worldwide. An adolescent is no longer isolated to his or her geographic location, but can find a social support network on the Internet on social networking sites. This access is not without risk, however. Some data show that LGBT people meeting others like themselves online also may engage in increased risk behavior (both sexual risk taking and substance abuse), particularly among men who have sex with men (MSM) who use such sites to meet sex partners. These data have so far been inconclusive and the risks must be weighed with the benefits.

Early/Middle Adults

Community

Many LGBT individuals experience support and nurturing from their biological families after coming out to them. For others, the support network of LGBT individuals may not include their biological family, as many families do not accept the sexual orientation or gender identity of the individual. In either situation, partners, friends, and community organizations can serve as an extended family. Primary care providers should be aware of a few useful resources to which they can direct patients (some resources are listed at the end of this chapter). LGBT people in rural or suburban geographic areas may have difficulty in accessing community-based support networks available in urban environments. In a study focused on MSM, those outside concentrated urban areas were less likely to identify as gay, be in a long-term relationship, be involved in a gay community, and were more likely to be out to a smaller number of people. In rural areas, a caring, open-minded physician may be an especially important source of support for LGBT patients.

Partners

Like most heterosexuals, the majority of LGBT people express a desire to find a partner and develop a relationship. And like heterosexuals, LGBT people can form and maintain long-lasting relationships. LGBT couples have commitment ceremonies and get married (in some localities), own homes together, share finances, and raise children. Physicians should be aware of local, state, and federal laws that allow LGBT individuals to codify their relationships with partners and children, ensure health care and retirement benefits, document advance directives, and secure inheritance rights.

Because of potential isolation from family, coworkers, and religious organizations, the relationship with a partner can be particularly important to an LGBT individual’s well-being. As a result, discord in the relationship may be even more stressful than it might be for heterosexual couples. In times of relationship stress, an individual may have limited resources for help in coping. Primary care providers should screen for such stressors and be able to provide appropriate referrals for individual and couple therapy.

Parenthood

Parenthood plays a role in the lives of many LGBT people, and the decision to become parents is usually deliberate and carefully made. LGBT individuals or couples may have children from previous heterosexual relationships or through adoption, artificial insemination, in vitro fertilization and surrogacy, heterosexual intercourse, or service as foster parents. Dual gay and lesbian couples raising children together is becoming more common.

Studies of the attitudes of gay and lesbian couples toward parenting find more similarities than differences compared with heterosexual couples. Children of gay or lesbian parents are no more likely to be gay or lesbian or to have gender identity confusion than the general population. Current evidence indicates that children of gays or lesbians develop normally and fare better in relationships where parents share responsibilities equally and have a low level of interpersonal conflict. Though they may face additional stigma in the school or community, children of gay or lesbian parents, like all children, are resilient and cope well with this challenge. Many professional medical associations, including the American Academy of Pediatrics and American Medical Association, have policies supporting same-sex, co-parent adoption.

Older Adults

Coming Out

Because there are varying degrees of disclosure, older individuals may be “out” to themselves and a partner or close friends but no one else beyond that trusted circle. Older gay, lesbian, or bisexual individuals are vulnerable to social isolation, and primary care providers are often among the primary support resources for older individuals. Older individuals are more likely to engage in same-sex sexual experiences prior to self-identifying as gay or lesbian than adolescents and thus may be at greater risk for adverse health consequences because of risky sexual behavior. In exploring the social support network for their older patients, primary care providers need to be alert to the possibility of a lesbian or gay identity and the needs this engenders.

Loss

Grief

Grieving the loss of a partner may be more difficult for a lesbian or gay man if that person does not have an adequate support system. Gay men and lesbians have been particularly affected by the deaths of partners and many friends from AIDS. When a partner dies, the survivor, in effect, loses a spouse. This fact often goes unrecognized in the survivor’s own social network. Frequently, the family of the deceased partner excludes the survivor or will not allow him or her to take part as a spouse in the funeral. A close-knit network of surviving friends is often neglected when a grieving family takes over funeral plans.

Occasionally, parents and family of the deceased are shocked and embarrassed to learn of the individual’s sexual orientation or gender identity. In such cases, the family may feel intense guilt or the need to hide their grief, unable to share it with their support network because of embarrassment. Family members of gay or lesbian individuals can find information and support for this and other issues by contacting Parents and Friends of Lesbians and Gays, a national organization with local chapters (see the list of resources at the end of this chapter).

Primary care providers can assist surviving partners and friends in the grieving process in several ways. Providers can assist the survivor in talking about the loss and expressing his or her feelings, identify and interpret normal grieving behavior and timelines, provide ongoing support throughout the grief process, encourage the survivor to develop new relationships and support structures, and help the survivor adapt to new roles and patterns of living. In some cases, the health care provider may be the only individual in whom the survivor can confide.

Advance Directives

The durable power of attorney for health care is particularly important for lesbians and gay men. Because many are unable to marry legally, LGBT individuals need to execute these documents to appoint their partners as surrogate health decision makers. Without such a document, current law considers the next of kin as the surrogate decision maker. Completing this document is the best way to avoid tragic decision-making conflicts between a partner and the estranged family members of seriously ill patients in time of crisis. As with all patients, providers should include a discussion of advance directives in the preventive medicine check up (see Chapter 40).

The American Psychiatric Association removed homosexuality from its list of mental disorders in 1973. Psychiatric and behavioral interventions like reparative therapy, used to “cure” patients of homosexuality, have proven neither effective nor necessary. Nonetheless, primary care providers must be aware of the unique psychosocial issues that face many LGBT people.

Depression & Suicide

Multiple studies indicate a higher prevalence of depression among both gay men and lesbians. Higher rates of suicidal behavior are also evident compared with the general population, though the prevalence is equivalent between gay men and lesbians. Lesbians are four times more likely to report suicidal ideation than heterosexual women, and gay men are six times more likely to attempt suicide than heterosexual men.

Adolescents are particularly vulnerable to depression and suicide. One report suggests that approximately one-third of gay or lesbian adolescents will attempt suicide. Much of the literature on this topic, however, comes from surveys of self-reported behavior subject to report bias. Whatever the exact prevalence of suicidality, gay, lesbian, bisexual, and transgender youth face additional risk of suicide related to coming out early, rejection by family members, rejection by religious institutions, interpersonal violence, and additional levels of marginalization (e.g., homelessness, racial and ethnic minority status).

Smoking

LGBT populations have a 1.6 times higher prevalence of smoking compared with heterosexual populations. The Women’s Health Initiative survey data documented a 10–14.4% smoking prevalence among lesbian respondents, compared with 7.2% among heterosexual counterparts. The Urban Men’s Health Study data indicate a 31.4% prevalence of smoking among MSM. Theories supporting the increased rates of smoking among these groups include higher levels of stress secondary to homophobia and discrimination, bars as a frequent social focus, potentially higher rates of associated drug and alcohol use, and targeted advertising by cigarette manufacturers. As with any group of patients, asking about tobacco product use is a vital part of the social history for LGBT individuals.

Substance Abuse

Inquiring about drug and alcohol use is also important for LGBT patients (see Chapter 24). A provider should specifically explore the type, frequency, and quantity of substances, and whether patients use them during or preceding sexual activity. Many substances have a disinhibiting effect on the user and may make individuals more likely to engage in unsafe sex practices. In a multivariate analysis of drug use among MSM, amyl nitrate (“poppers”), crystal methamphetamine (“crystal meth”), cocaine, and heavy alcohol use were all associated with unprotected anal intercourse, independent of partner-specific variables. Similar to many other populations, crystal meth, with its highly addictive potential, has had a profound impact on many gay men. There is a strong association between crystal meth use and prolonged, unprotected sexual activity. Although drug and alcohol use is an important issue for the entire LGBT population, there is controversy about its extent. Based on more recent literature, alcohol use among gay men is probably the same as or slightly more prevalent than among heterosexual men. Drug use is more common among gay men compared with their heterosexual counterparts. According to a comparison of a population-based sample of lesbians in the San Francisco Bay area with a control group, alcohol use appears to be no more prevalent among lesbians than among heterosexual women. There are no population-based studies of drug use among lesbians compared with heterosexual women.

Intimate Partner Violence

Contrary to some popular beliefs, battery of LGBT persons by their partners exists. The exact prevalence of battery in same-sex relationships is unknown, but recent literature suggests the rate of same-sex intimate partner violence to be at least equal to that of opposite-sex intimate partner violence. Unfortunately, gender-role stereotyping both in the likelihood of the perpetrator inducing injury (men more capable than women) and the seriousness of the violence (women are more likely to sustain serious injury) exists and likely influences the recognition of same-sex intimate partner violence, the consequences to the perpetrator, and empathy for the victim. Lesbians perceive that interpersonal power imbalances contribute to battery. They also report that many women’s shelters are not responsive to their specific needs. Gay men may find it even more difficult to obtain services related to battery.

Minority stress (e.g., internalized homophobia, discrimination) negatively influences same-sex intimate partner violence perpetration and victimization among LGBT persons. There is likely a similar, if not greater, effect among transgender individuals. Health care providers should screen their LGBT patients—and all patients—for the possibility of intimate partner violence and be able to give referrals to LGBT-inclusive resources, including shelters and counselors (see Chapter 38).

Hate Crimes

Also known as bias crimes, these are words or actions directed at an individual because of membership in a minority group. The U.S. Department of Justice reports that LGBT individuals may be the most victimized group in the nation and that the incidence of hate crimes against LGBT persons is rising. Many studies report crimes ranging from verbal abuse and threats of violence to property damage, physical violence, and murder. The number of hate crimes reported by LGBT persons is increasing every year. Lesbians at universities, for example, report being victims of sexual assault twice as often as heterosexual women. Youths who report same-sex or both-sex romantic attractions are more likely to be both victims and witnesses of violence.

Perpetrators of hate crimes often include family members and community authorities. Many gay and lesbian adolescents leave home because of an abusive family member, and homeless LGBT youths are of increasing social concern. LGBT survivors of hate crimes display more symptoms of depression, anger, anxiety, and posttraumatic stress than other recent crime victims. When patients present with symptoms of depression or anxiety, providers should consider violence, including hate crimes, as a possible correlate.

Patient Education

This is a cornerstone of primary care. Providers who care for LGBT patients must know how to advise patients on health issues, refer them to appropriate educational and community resources, and provide appropriate reference materials to hand out at visits.

Instruction

Instruction in preventing the spread of HIV and other sexually transmitted diseases should be clear and specific to individual sexual practices. Physicians should be able to educate LGBT patients about risks and screening for cancer. They should be able to counsel patients, or refer them for counseling, about issues such as safer sex, parenting, coming out, violence, substance use, and depression.

Referrals

Referrals should include other providers and community-based resources sensitive to the needs of LGBT people. Specialists of particular importance to delivering appropriate, multidisciplinary care include gynecologists, urologists, general or colorectal surgeons, plastic surgeons, and endocrinologists. Local resources with which to be familiar include bookstores, youth groups, senior groups and retirement centers, community centers, supportive religious organizations, substance abuse treatment programs, and support groups. LGBT-oriented periodicals from a nearby urban area may have resources listed for surrounding suburban and rural regions.

Provider Education

Health care providers can obtain additional information about specific health issues and communicating with LGBT patients through textbooks, review articles, teaching videos, and workshops at both national and regional medical conferences. See below for details on individual resources.

1. General Resources

• Gay and Lesbian Medical Association. www.glma.org. Accessed July 2013.

  • Resources for providers and patients

  • Provider referral network

• The GLBT Health Access Project. www.glbthealth.org. Accessed July 2013.

  • Community standards of practice for provision of quality health care services for LGBT clients

  • Educational posters

• National Coalition for LGBT Health. http://lgbthealth.webolutionary.com/. Accessed July 2013.

• National Association of Gay and Lesbian Community Centers (Centerlink: The Community of LGBT Centers). www.lgbtcenters.org. Accessed July 2013.

  • Directory for centers throughout the United States

• GLBT National Help Center. www.glnh.org. Accessed July 2013.

  • National nonprofit organization offering toll-free peer counseling, information, and local resources, including local switchboard numbers and gay-related links: 888-THE-GNLH (843-4564)

• GLBT National Youth Talkline: 1-800-246-PRIDE (7743)

  • Youth peer counseling, information, and local resources, through age 25

2. Lesbian Health

• Lesbian Health & Research Center. http://www.lesbianhealthinfo.org/about/index.html. Accessed July 2013.

• Mautner Project, the National Lesbian Health Organization. www.mautnerproject.org. Accessed July 2013.

• Lesbian and Bisexual Health Fact Sheet. www.womenshealth.gov/publications/our-publications/fact-sheet/lesbian-bisexual-health.cfm. Accessed July 2013.

3. Gay Men’s Health

• The CDC Gay and Bisexual Men’s Health Page. www.cdc.gov/msmhealth/. Accessed July 2013.

• Gay Men’s Health Crisis. www.gmhc.org. Accessed July, 2013.

• NYU Medical Center—Men’s Sexual Health Project (M*SHP). www.hivinfosource.org/hivis/clinicaltrials/testingproject.html. Accessed July 2013.

  • A New York City-based group with link to low literacy STI information

4. Bisexual Health

• Bisexual Resource Center. www.biresource.net. Accessed July 2013.

5. Transgender Health

• World Professional Association of Transgender Health. www.wpath.org. Accessed July 2013.

• International Foundation for Gender Education. www.ifge.org. Accessed July 2013.

• Transgender Law Center: recommendations for transgender health care. www.transgenderlaw.org/resources/tlchealth.htm. Accessed July 2013.

6. Youth

• The Trevor Project. www.thetrevorproject.org. Accessed July 2013. 1-866-4-U-TREVOR (1-866-488-7386).

  • A national organization providing crisis intervention and suicide prevention services to lesbian, gay, bisexual, transgender, and questioning (LGBTQ) youth. Services are available by phone or online chat.

• National gay, lesbian, bisexual, transgender youth hotline: 1-800-347-TEEN

• Youth Guardian Services: on-line support. www.youth-guard.org. Accessed July 2013.

• Youth Resource: a project of Advocates for Youth. http://www.amplifyyourvoice.org/youthresource. Accessed July 2013.

• National Youth Advocacy Coalition: Youth Guide. www.nyacyouth.org. Accessed July 2013.

7. Elders

• SAGE: Services and Advocacy for Gay, Lesbian, Bisexual, and Transgender Elders. www.sageusa.org. Accessed July 2013.

8. Support and Resources for Family and Friends of LGBT People

• PFLAG (Parents, Families, and Friends of Lesbians and Gays). www.pflag.org. Accessed July 2013.

  • Promotes the health and well-being of gay, lesbian, bisexual, and transgender persons, their families and friends

9. Intimate Partner Violence

• National domestic violence hotline 1-800-799-SAFE (7233) (24 hours in English and Spanish), TTY: 1-800-787-3224

  • Local referrals, including LGBT-sensitive

• The Network La Red: Network for battered lesbians and bisexual women hotline. www.thenetworklared.org. Accessed July 2013. Hotline: 1-617-742-4911

10. General Information: National LGBT Rights and Advocacy

• Human Rights Campaign. www.hrc.org. Accessed July 2013.

  • National organization working for LGBT equal rights on federal government level

• Lambda Legal. www.lambdalegal.org. Accessed July 2013. Legal helpdesk: 1-866-542-8336

  • National LGBT legal and policy organization protecting civil rights of LGBT and people living with HIV

• National Center for Lesbian Rights. www.nclrights.org. Accessed July 2013. Hotline: 1-415-392-6257

• National Gay and Lesbian Task Force. www.thetaskforce.org. Accesssed July 2013.

  • National organization supporting LGBT advocacy efforts at state and federal levels

11. Media/brochures (for Waiting Room)

• American Cancer Society. http://www.cancer.org/search/index?QueryText=cancer+facts+for+LGBT. Accessed July 2013.

  • Cancer facts for gay and bisexual men

  • Cancer facts for lesbians and bisexual women

  • Tobacco and the LGBT community

  • Place order for free brochures by phone: 1-800-ACS-2345

• American College Health Association. http://members.acha.org/source/orders/index.cfm?section=unknown&task=1&StartRow=1&PageNum=1&SEARCH_TYPE=find&FindSpec=&continue=1&CATEGORY=BROCHURES&FindIn=. Accessed July 2013.

  • Man to man: three steps to health for gay, bisexual, or any men who have sex with men

  • Woman to woman: three steps to health for lesbian, bisexual, or any women who have sex with women